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HomeMy WebLinkAbout040-1263-80-000 K Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and � � Division County: INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal informtion you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 384119 Permit Holdees Name: ❑ City ❑ Village ❑ own of: State Plan ID No.: W illiams, Chris Troy Township T BM E ev_: Insp. BM E ev.: BM Description: Parcel Tax No.: 5 l CST gnt, Z t�c.e = w�• -r-( ��•�+rre • 040 - 1263 -80 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic( Benchmark Dosing - — Alt. BM 0.0 121.04. r Aeration . Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet S. S 5 TANK TO P/ L WELL BLDG. Air i to ntake ROAD Dt Inlet Air I Septic �I, D r NA Dt Bottom — Dosing NA Header/Man. f 2 "� 8 •S"7, Aeration A Dist. Pipe f 2 . ('o fl $ • y Holding Bot. System / ' ° o • C) PUMP/ SIPHON INFORMATION Final Grade •�- 9.1 111. 1' - : 1 7 Manuf urer and St cover Gr - ►ICE Model Nu4dker GPM TDH I Lift ion I S tem T Ft Forcemaln I Length Dia. Dist.Towell SOIL ABSORPTION SYSTEM ) 4w4 RENCHI Width Length r No Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth N • 19 . .... DIMENSION LEACHING any act er: SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM r- S9Wt INFORMATION Type O CHAMBER M c N m r: System: 2$ 55 OR UNIT DISTRIBUTION SYSTEM Header/Manifold u Distribution Pipe(s) x Hole' x Hole Spacing Vent To A r Intake Length Dia. ia. pacing 5 SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over y Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Trench Center N. + Bed I Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes CO] No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: D21 AP/ 61 Inspection #2: • —f—f Location: 413 New Cent D �ve, Hudson WI 54016 (NW 1/4 SW 1/4 5 T2 N R 9W) - 05 8191426 Frontier -Lot 18 1.) Alt BM Description- (o(, i 0 /ViC etch ¢l ��oweS �`^ 2.) Bldg sewer length = 1 0 - amount of cover � -3 W s �-t1 5 r ec�t�• -�`wte . P n revision required. ❑ Yes No w Use other side for additional information. 02 O SBD -6710 (R.3(97) Date Inspectors Signature Cert. No. r a 4 a P Q i i�� phi �- r t # AfI3 N E R- Sanitary Permit Application Safety & Buildings Division Q W A ILI E In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 s�n l� Personal information you provide may be used for secondary purposes Madison, W153707 -7302 Deportmeot;of;Commerce [Privacy Law, s. 15.04(ixm)] (Submit completed form to county if not state owned. Attach complete plans to the county copy only) for the system, on paper not less than 8 -1/2 x I 1 inches m size. County State Sanitary P it Number Check if revision to previous application State Plan 1. D. Number I. Application Information - Please Print all Information Location: Property Owner Name Property Location T / r' . J t!�i� 1146 1/4 S J T N R' or Property Owners Mailing Address Lot Number Block Number . _ 1 City, State Zip Code Phone Numb& Subdivision Name or CSM Number II. Type of Building: (check one) ❑ city Q< l or 2 Family Dwelling -No. of Bedrooms : ❑ Village ❑ Public/Commercial (describe use):_ JRTown of -/ ❑ State -Own Iro Nearest Road Parcel Tax Number(s) _ .. III. T Ype of Permit: Check only oWe box on line A. Check box on line B if applicable A) 1. kNew 2. ❑ Replacement 3. O Replacement of 4. 5. 6. 0 Addition to System System Tank Only Existing System B) 13 Permit Number Date Issued , A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) --'E — Ian ' (Non- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland • Pressurized In -ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line • At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information: 1. Design flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Ele vation 7. Final Grade Require } Proposed Rate (GalsJday /sq. ft.) (Minlinch) Elevation G OD 5r./ V � s I r I v �Y • 0 ' \ VIL Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete strutted Tanks Tanks VIII. Responsibility Statement I the undersi ed, assume responsibility for installation ofthe POWTS shown on the attached plans. Plumbers Name (print) Plumber's Signa (no stamps): WARS No. Business Phone Number o a t " Plumbers Address (Street, City, %ite, Zip Code 1 f I l e � � y • � L.�� IX. County/Departifient Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued g Agent Si (No stamps) Approved 0 Owner Given Initial Adverse S Fee) Determination � s7. CD e2 —05 2b& 1 X. Conditions of Approval /Reas ns for Disap r Val: Q L�rru' rs s'. ( �aDs J�� � t. �� f ms t+�5 `G e"� . W"4 " be C xe o rea��VK���a f,.taQ c+s p o IN. 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Soil &Site Evaluations Attach complete site plan on paper not less than 8' /z x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. parcel I.D.# Prt of 040 - 1022 -10 APPLICANT INFORMATION - P aekprint all information. R viewed B y Date Personal information you provide may be u tr secondary qurposes (Privacy Law, s. 15.04 (1) (m)). - Property Owner r Property Location Miller Sans Govt. Lot NW 1/4 SW 1/4 S 5 T 28 N,R 19 W Property Owner's Mailing Address - n , , - Lot # Block # Subd. Name or CSM# P.O. Box 151 18 City State Zip Code" ' Ph *umber ❑ City I] Village ®Town Nearest Road Hudson W1 54016,,; 71 ..- 9 Troy ® New Construction ❑ Use: Residential /, -Nr O� `n,`h rooms 4 ❑Addition to existing building ❑ Replacement ❑ Pubkot describe Code Derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd/ffs .8 trench, gpd/fts Absorption rea required 857 bed, ft' 750 trench, ftz ' um design loading rate .7 bed, gpd/ft .8 trench, 9pd� Recommended infiltration surface elevation(s) 106.50x ft (as referred to site plan ben mark) Additional design / site considerations hlstall trenches using high capacity infiltrators. Parent material Glacial outwash loud lain a va ,If a licable NA ft S= Suitable for system Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank U= Unsuitable for system MS 0 u ® S❑ U ® S 0 u ® S❑ U ❑ S ®u ❑ S E u SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure Consistence GPDlftz Boring# Ho in. Munsell Qu. Sz. Cont. Color Texture t Sz Boundary Roots Bed Trench 1 1 0 -8 1Oyr2 /2 None sl 2msbk mvfr as 2fin,lc 0.5 0.6 2 8 -21 10yr4 /4 None sil lthinpl mfr aw 2fin,lc NP 0.3 Ground 3 21 -30 7.5yr4/6 None ifs lmsbk mvfr gw if &m 0.5 0.6 elev 114.15 ft 4 30 -71 10yr5 /4 None gr. s Osg dl gs - 0.7 0.8 Depth to 5 71 -124 10yr6 /4 None gr. s Osg dl - - 0.7 08 _ limiting factor o ? >124" �— Remarks: 2 1 0 -11 1Oyr2 /2 None sill 2fcr mvfr as 2frn,lc 0.5 0.6 2 11 -25 10yr3 /3 None sil lthinpl mfr aw 2fin,lc NP 0.3 P' Ground 3 25 -33 7.5yr4/4 None co. sl lmsbk dsh gw 1%m 0.4 0.5 elev 108.55 ft 4 33 -80 10yr5 /4 None gr. s Osg dl gs - 0.7 0.8 Depth to 5 80 -122 1Oyr6 /4 None s Osg dl - - 0.7 0.8 limiting factor >122' - Remarks: CST Name (Please Print) Signature: , �� -- - Telephone No. James K. Thompson �.s � 715- 248 -7767 Address A.C.E. Soil & Site Evaluations Date CST Number Ref # 340 Paulson Lake Lane, Osceola, 454020 12/31/1999 3602 1167 PROPIRrYOVMER: Miller, Sam SOIL DESCRIPTION REPORT 1187 Page 2 of 3 •PARCEL LD.# Prt ofo40- 1022 -10 A-C.E. Sod & Site Evaluations Depth Dominant Color Mottles Structure sistence Boundary Roots GPDIft2 Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Bed :Trench 3 1 0 -9 10yr2/2 None sil 2fcr mvfr as 2f &m 0.5 0.6 2 9 -21 10yr3 /3 None sil lthinpl mfr aw 2f &m NP 0.3 Ground elev 3 21 -40 7.5yr4/6 None gr. Is Osg dl gw if &m 0.7 0.8 109.25 ft 4 40 -85 10yr5/4 None gr. s Osg FdI gs - 0.7 0.8 Depth to 5 85 -117 10yr6/4 None s Osg - - 0.7 0.8 limiting factor - >117' 33 Cl - LL Remarks: 4 1 0 -8 10yr2/2 None sl 2msbk mvfr as L2fin,Ic 1c 0.5 I 0.6 2 8 -20 10yr4 /4 None g a r ssl ` 2msbk mfr aw NP 0.3 Ground elev 3 20 -27 7.5yr4/6 None Is Osg dl gw if &m 0.7 0.8 103.14 ft 4 27 -80 10yr5/4 None gr. s Osg dl gs - 0.7 0.8 Dew ip 5 80 -122 1 Oyr6 /4 None gr. s Osg dl - - 0.7 0.8 limiting factor >1 Remarks: 5 1 0 -8 10yr2 /2 None sl 2msbk mvfr as 2fm,lc 0.5 0.6 2 8 -29 1Oyr4/4 None sil lthinpl mfr aw 2frn,lc NP 0.3 Ground elev 3 29 -40 7.5yr4/6 None Ifs lmsbk mvfr gw if &m 0.5 0.6 112.24 ft 4 40 -88 10yr5/4 None gr. s Osg dl gs - 0.7 0.8 Depth to 5 gg -113 10yr6 /4 None gr. s Osg dl - - 0.7 0.8 limiting facto >113' Remarks: Ground elev Depth to limiting factor Remarks: * OWf7 ,ro Pa 3 oF'3 /o6 1 - 7 13 ■ ;/ Q� s�Nl1 cY Nta; ► 1 r� T. o ff' 7i�,y� 5t • �'- �'Di,r C'D; L0 El rn �le� �iPw =rrs z6' J N r \6 d ta f � Z: SMet Bt �3 ■ i4r-e ►p10 Lp 7% Slo Q N sz� ■, B`► Cedarfi' / 4ss4,n e /rK Lot 119 ,lot / 7 .Z�YS Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In- Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83,54, Wis. Adm. Code, and the In- Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- 10567-P (R.6/99). Table 1: System Design Specifications Sanitary Permit Number Number of Bedrooms Design Flow - Peak (gpd) 0 Estimated Flow - Average (gpd) 00 Septic Tank Capacity (gal) 12 6o W ae-�-s Soil Absorption Component Size (W) Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) 1 .2w Z — as Rgl iks Maximum Influent Particle Size (in) V 1/8 Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. Th out et filte shall be cleaned as necessary to ensure proper operatio The filter cartridge shoul not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the Management Plan for a Septic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason without being in full compliance with OSHA standards for tic or other entering a confined space. The atmosphere within the septic treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure i s designed g to accept domestic I The limits of operation of this astewater from a residential facility. component are shown in p p Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. o Went should be avoided articular) or over the soil absorption coin particularly Traffic around p p during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 r Management Plan for a Septic Tank and Soil Absorption Component Plantings of deep- rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. 3 sT cRoIX cOUNI`Y SEPTIC TANK MAINTE NANCE AGREEMENT AM 4WNERSIIIP CERTIFICATION FORM k wner/B er failing ddress �7 f ropesrty 4 rtment for new construction) - --� (Verification required from Pla Depa :tty /stat 1 Parcel Identification Number TGAY �ESCRTI'TI T om- N_g�W, .. Town of ray -- ---. -- 'roperty ! _'!�, Sec. — __- / Lot it 1 ..- 3ubdivisi on Cer"I Survey Map # Volume Page wan-an y Deed # 3 7 ��� ______, Volume Page # Lot lines identifiable 5P Yes ❑ no Spec 1'0 p yes no #Sff ' rema ture failure to handle wastes. Proper maintenance roper use and maintenanceof your septic system cou result in its a licensed pumper. What you put into the system umping out the septic tank every three years or sooner, if needed y consists e function of the septic tank as a treatment stage in the waste disposal system,. Dc arlment a certification form, signed by the owner � s ystem e property owner agrees to submit to St. Croix 'Zoning p that (1) the o11-site was tewater disposal Y utastcrpl jourueymanplumbcr, actedplumberoralicensedpumperW�Y� o rating condition and/or (2} after inspection and pumping (if necessary), the septic tank is l ess than 1/3 f of sludge. is m p pe system with the standards ed have read the above requirements and agree to maintain the private sewage d certification Uwe: the undersign D of Natural Resources, State o€ Zonin s office within 30 set forth, herein, as set by the Department of Commerce and the stating t your septic system: has been maintained must be completed and returned to the St. Croix County Zoning days of I he three year expiration date. DATE 7sK A IM OF APPLICA.NU UW g. ,CER n _FICATI0 our knowledge. I (we) am (are) the owners) of I (we) certify that all statements an this form are t ru e the best of te of Deeds Office. the property descri Bove, by virtue of a warranty deed rec to in Reg i f 0 6 4 O / FAPPL DATE CANT * «* « «« i ermit being revoked by the Zoning Department, « « « +• Any information that is mis- represeatedmay result in the sanitary p *s Inc' ude with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed I VOL 1579PAC� 335 STATE BAR OF WISCONSIN FORM 2 - 1998 1�3 s� WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS Document Number ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between Sam E. Miller, a 01 -29 -2001 8:00 AN single person, WARRANTY DEED EXEMPT N Grantor, CERT COPY FEE: and Chr istopher -- g. Williams and COPY FEE: Jacqueline A.. Williams, husband and TRANSFER FEE: 195.00 wife as survivorship marital property, RECORDING FEE: 10.00 PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Cro i X County, State of Wisconsin: Recording Area Name and Return Address First Federal Savings Bank LaCrosse— Madison 201 South Second Street Hudson, Wisconsin 54016 040 - 1263 -80 -000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Lot 1 Plat of Frontier in the Town of Troy, s "Croix County, Wisconsin. j' I I' � Exceptions to warranties: ; Su bmect to easements, reservations and restrictions or record. Dated this day of January 2001 SEAL` SEAL * SAM E. MILLER (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, 55. St. Croix Coon authenticated this day of Personally came before me this day of January 2001 , the above named Sam E. Miller TITLE: MEMBER STATE BAR OF WISCONSIN to (If not, $ 6t m known to be the person who executed the foregoing authorized by §706.06, Wis. Stats.) ,O S =sltument and acknowledge the same. J �lC_'d li THIS INSTRUM ll wAs DRAFTED BY wil��3`I EGr UNLAP uun Hudson, Wisconsin Not ry P blic State of Wisconsin My co mission is perman t. (If not, state expiration date. (Signatures may be authenticated or acknowledged. Both are not ` A 0 necessary.) i * Names of persons signing in any capacity must be typed or printed below their signature. 1 STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. WARRANTY DEED FORM No. 2 - 1998 Milwaukee, Wis. , r iR�J7!'FS�� le �nr r� N 00'13 W 460.08 FT • ou.h.m Oem 1004.9c FT IT 31 k" IT _ r it _ ■ - 0 �..� 004:'44' W C c • 9 `` 604, rT s 1 � N ' ai '3 �p ✓ `'' — LOU ` ■ r ^a7stt:r.. 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